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INVISIBLE Part 1 of 3

“Invisible,” by Marianna Crane, originally appeared in the Examined Life Journal.

The cardinal rule of the game is that open disagreement between the players must be avoided at all costs. Thus, the nurse must communicate her recommendations (to the physician) without appearing to be making a recommendation statement. – – – The greater the significance of the recommendation, the more subtly the game must be played.

– 1967, Leonard I. Stein, M.D.

I left my patient, Ms. O, dozing in her hospital bed. Heading towards the nursing station, I clenched and unclenched my fists, steeling myself to make a call I didn’t want to make.

When I first ambled into Ms. O’s private room that morning, she was sitting up in bed with a breakfast tray in front of her. Her knobby fingers put down a half eaten slice of toast. The eggs and sausage were untouched.

“I’m done. I just want to keep the coffee.” I removed the tray and slid it onto the food cart standing in the hallway. Back in the room, I noticed a stale, musty odor. Sunlight filtered through the only window highlighting Ms. O’s greasy and matted hair. “How about washing up?” I said.

Ms. O’s pale face lit up with a smile. “I’d just love a shower.”

“Sure. Finish your coffee while I get the linens.”

It was the summer of 1980. I had just completed the first year of a two-year master’s degree program in nursing. I had taken this part-time job, working a couple of days a week, in a small community hospital near my home. When classes started back up, I figured, I would juggle being a full-time student with doing what I loved—caring for patients.

Outside of Ms. O’s room, my arms laden with sheets, towels and a hospital gown, I was aware of a tall man as he breezed by me, his copious belly encased in a dark suit. Over his shoulder he shouted back into Ms. O’s room, “See you in my office next week.”

“My doctor just told me I’m going home today,” Ms. O said, as I unfolded the fresh towels. Her chuckle, which trickled up her throat, exploded into a racking cough. When the episode was over, she sank back into her pillow, breathing deeply. Had her doctor heard that cough? He couldn’t have been in her room more than a minute or two.

“Are you okay?” I asked. The night nurse had recorded that Ms. O slept well and hadn’t indicated any problems. Ms. O gave me half a smile but didn’t speak.

“Well,” I said, “let’s get you up, showered and dressed.”

Pushing off the covers, Ms. O inched her legs toward the edge of the bed until they dangled over the side. Her bony hand pulled on my arm as she swiveled to a sitting position. This effort set off another coughing fit. What’s going on here?“ How long have you had that cough?”

“A couple of days. Seems to have gotten worse.”

Bending down, I pressed the skin over her thick ankle. My finger left a half-moon print on her leg.

“Do you usually have swelling in your legs?”

Ms. O glanced down. “No.”

“Who will be home with you?”

“I live alone.”

Something wasn’t right. I pulled out my Littmann stethoscope, a gift to myself after successfully completing the last class of the semester: physical assessment. In that course, my fellow nurse practitioner students and I learned how to take a patient’s history. We used each other to hone our diagnostic skills: we probed bellies with our fingers, placed stethoscopes over lungs, and tapped elbows and knees with a rubber hammer. We hadn’t practiced on patients yet. Instead, we listened to tapes in the computer lab of heart valves leaking, lungs wheezing and large intestines gurgling.

“I want listen to your lungs.” With my hand on Ms. O’s shoulder, I nudged her forward and placed my stethoscope on her scrawny back. What filled my ears were not the same clear blowing reverberations of my classmates’ young, disease-free air passages. What was I hearing? Rales? Rhonchi? Wheezing? The names of abnormal sounds jumbled in my head. “Cough, please,” I said, trying to sound like I had done this for years. We had learned that semester that coughing would clear mucus from airways, resulting in normal breath sounds. After coughing, Ms. O’s lungs were still waterlogged. I straightened up and pocketed my stethoscope.

Ms. O interrupted my thoughts. “I need to go to the bathroom.”

I didn’t like the pasty color of her face or the way her chest rose and fell with each breath. Better she stayed in bed. “Let me get you a bedpan.”

After helping her lie back, I raised her hips and slipped a blue plastic bedpan under her bottom. When I retrieved the bedpan a few minutes later, it was empty.